The home health aide caring for a home bound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?
Listen for the presence of bowel sounds.
Teach the client about foods high in fiber.
Administer a prescribed dose of a laxative.
Assist the client in drinking warm prune juice.
The Correct Answer is D
Choice A Reason: Listening for the presence of bowel sounds is not a task that the home health aide can perform, as it requires a stethoscope and clinical judgment. This task is within the scope of practice of the nurse, who should assess the client's bowel function and abdominal status.
Choice B Reason: Teaching the client about foods high in fiber is not a task that the home health aide can perform, as it requires knowledge and education skills. This task is within the scope of practice of the nurse, who should provide dietary advice and counseling to the client and their family.
Choice C Reason: Administering a prescribed dose of a laxative is not a task that the home health aide can perform, as it requires medication administration skills and authority. This task is within the scope of practice of the nurse, who should check the medication order, verify the dosage and route, and document the administration.
Choice D Reason: Assisting the client to drink warm prune juice is a task that the home health aide can perform, as it requires basic care and assistance skills. This task is appropriate for the home health aide, who should encourage fluid intake and offer natural remedies for constipation, such as prune juice, which has laxative effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) This client has a mild fever, which may indicate an infection or inflammation. This is a potential complication of enteral feedings, but it is not the most urgent situation. The nurse should monitor the client's vital signs, assess the feeding tube site, and notify the provider if the fever persists or worsens.
B) This client has signs of uremic encephalopathy, which is a life-threatening condition caused by the accumulation of toxins in the brain due to impaired renal function. The nurse should intervene immediately to prevent further
neurological damage and possible coma or death. The nurse should assess the client's level of consciousness, check the blood pressure and urine output, and prepare to administer dialysis or other treatments as ordered by the provider.
C) This client has heat stroke, which is a serious condition that can lead to dehydration, electrolyte imbalance, and organ damage. However, the client is receiving a normal saline IV fluid bolus, which is an appropriate intervention to restore fluid volume and correct sodium levels. The nurse should continue to monitor the client's vital signs, skin
temperature, and urine output, and watch for signs of fluid overload or cerebral edema.
D) This client has hyperemesis gravidarum, which is a severe form of nausea and vomiting during pregnancy that can lead to dehydration, malnutrition, and electrolyte imbalance. However, the client is receiving an infusion of Ringer's Lactate, which is an isotonic solution that can replenish fluid and electrolyte losses. The nurse should continue to monitor the client's vital signs, weight, and intake and output, and administer antiemetics or other medications as ordered by the provider.
Correct Answer is D
Explanation
Choice A Reason: Announcing the new plan at a special employee wellness event may be a good way to promote the plan and celebrate the achievement, but it is not the most important action. The nurses working on the committee should first communicate the plan to their colleagues and address any questions or concerns they may have.
Choice B Reason: Determining staff opinion of current healthcare insurance costs may be useful for evaluating the need and feasibility of the new plan, but it is not the most important action. The nurses working on the committee should have done this before developing and approving the new plan, not after.
Choice C Reason: Surveying the nurses to see who wants to keep the old benefits plan may be helpful for assessing the satisfaction and acceptance of the new plan, but it is not the most important action. The nurses working on the committee should have considered the preferences and needs of their colleagues during the development and approval of the new plan, not after.
Choice D Reason: Being available to all shifts to discuss the changes in health benefits is the most important action for the nurses working on the committee to implement, as it shows respect and transparency for their colleagues, and fosters a collaborative and supportive work environment. The nurses working on the committee should explain the rationale and benefits of the new plan, and provide feedback and guidance to their colleagues.
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